[Ultrasound education by simulator training high acceptance by ultrasound trainees of all qualification levels]. / Ultraschallausbildung am Ultraschallsimulator.

Ultrasound education improves by simulator training, however, the acceptance of ultrasound simulator training has not been investigated. Therefore we evaluated the participants response to simulator education during an ultrasound course of abdominal emergencies at an international ultrasound congress, at a regular ultrasound course and during courses at a regional hospital and an university hospital. Altogether, 62.3% of the participants judged the simulator image quality to be good. 84.3% considered the case selection to be good and 92.7% of the participants viewed the educational benefit to be good. 98.5% whished to have further ultrasound simulator courses to be developed and 95.3% of the participants opted for the integration of simulator training into the conventional ultrasound education.

[Improvement of ultrasound education by simulator training]. / Verbesserung der Sonographieausbildung durch Schulung am Ultraschallsimulator.

Ultrasound education is complicated by varying quantities and qualities of specific pathologies resulting from distinct patient collectives. Furthermore, under current clinical conditions ultrasound educators as well as trainees frequently lack the time necessary for a sufficient ultrasound education. Finally, current ultrasound education materials including "gold standard" images are not ideally suited for teaching scanning three-dimensional pathologies. An improvement of ultrasound education is feasible by training ultrasound trainees on an ultrasound simulator we developed. By using this simulator as well in the classical beginner and advanced level courses as in focused courses of abdominal emergencies or general practice for instance, ultrasound trainees are able to practice scanning of numerous well defined pathologies under realistic conditions.

[New concepts in ultrasound education in gastroenterology by simulator training]. / Neue Konzepte in der gastroenterologischen Sonographieausbildung durch Schulung am Ultraschallsimulator.

Ultrasound is one of the most important imaging methods in medicine. However, ultrasound education is complicated by varying quantities and qualities of specific pathologies resulting from distinct patient collectives. Furthermore, under current clinical conditions ultrasound educators as well as trainees frequently lack the time necessary for a sufficient ultrasound education. Finally, current ultrasound education materials including "gold standard" images are not ideally suited for teaching scanning three-dimensional pathologies. In a direct cross over study we recently proved, that the ultrasound simulator we developed simulated the real patient examination reliably and reproducibly. By using this simulator as well in the classical beginner and advanced level courses as in focused courses of abdominal emergencies for instance, ultrasound trainees are able to practice scanning of well defined pathologies under realistic conditions, which has not been possible before. Furthermore, the ultrasound simulator is well suited for a structured ultrasound training in single hospitals as well as in continuous medical education. Finally, objective, standardized ultrasound quality control has become possible with the simulator.

Simulation of abdomen sonography. Evaluation of a new ultrasound simulator.

AIM: We developed and evaluated a simulator for the sonography of the abdomen in order to improve the teaching quality in sonography training. METHOD: Eleven medicine residents who had received 4 to 12 months full time sonography training performed ultrasound examinations of the right upper quadrant in 5 consecutive patients and in 5 simulator cases. The correctness of their findings and the time required for the examinations were measured. The subjective confidence in their findings and the handling of the ultrasound machines were rated on a visual analogue scale. RESULTS: During patient ultrasound examination 75 % (SEM 9%) of all pathologic findings were recognized by the residents, whereas 71 % (SEM 8%) of the pathologies of the simulator cases were found. This minimal difference was not significant in the paired, two sided t-test (p = 0.15). Severe pathologies did not escape detection. The time required for patient examination(10.57 min, SEM 3.25 min) was not significantly different (p = 0.53) to the time required for the simulator cases (9.59 min, SEM 2.98 min). The subjective confidence in the sonographic findings did not differ significantly (p = 0.39) between the real patient situation (68%, SEM 6%) and the simulation (64%, SEM 12 %). Only the handling of the ultrasound machines was judged to be significantly better (p=0.008) than the simulator (74%,SEM 7% vs. 61 %, SEM 12%). CONCLUSION: In this first direct crossover comparison between real patient sonography and simulator based scanning we proved that the simulator we developed simulates the real patient examination reliably and reproducibly.

The long-term involution of physiological cardiomegaly and cardiac hypertrophy.

The long-term involution of physiological cardiomegaly and cardiac hypertrophy. Med. Sci. Sports Exerc., Vol. 21, No. 3, pp. 244-249, 1989. Forty-five former athletes in endurance disciplines, primarily Olympic medalists and World Cup, European Cup, and German champions, for whom results of an exercise ECG and radiological heart volume measurement were available from their active competitive phase, were examined. The study protocol included clinical examination, laboratory controls, resting and exercise ECG, determination of cardiac volume, and one- and two-dimensional echocardiographic examination. Of the 45 former athletes contacted, 38 appeared for examination. Of these, four presented with heart disease (two with infarction, one with aortic stenosis, and one with arrhythmia). The remaining 34 were divided into groups of still active (more than 300 kcal.wk-1) and inactive (less than 300 kcal.wk-1) athletes. The interval between the first and second examination averaged 23 yr. The active former athletes showed a weight increase of 5.2% (P less than 0.01) and a reduction of 14% in ergometric performance (P less than 0.02). The inactive group had a marked weight increase of 17.4% (P less than 0.001); the ergometric performance was lowered by 20% (P less than 0.001). The absolute heart size had decreased in the active group by 6.1% (NS) and the relative heart size by 10.7% (P less than 0.005); the corresponding values in the inactive group were 4.5% (NS) and 18% (P less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

[Capacity for regression of the athletic heart]. / Rückbildungsfähigkeit des Sportherzens.

Dynamic exercise leads to an increase in heart size and to hypertrophy depending on the intensity and extent of training. The maximum of left ventricular muscle mass is reached at 3.5 g/kg, which is 70-80% higher compared to untrained subjects. The mass/volume ratio remains constant (left ventricle 1.0-1.2 g/ml). Systolic wall stress and ejection fraction of the enlarged left ventricle do not change. No heart hypertrophy can be found in athletes carrying out maximum static exercise. Heart size and heart hypertrophy regress when training stops completely. The velocity of regression is not exactly known, a maximum regression of 10-15% within three weeks is probable. Investigations of former athletes show a decrease of heart size and heart hypertrophy, especially when related to body weight. The degree of regression depends on the actual physical activity; another factor may be the duration of the competition activity. It is supposed that only a small degree of training prevents the decrease of heart enlargement, heart hypertrophy and higher performance ability. Damage to the cardiovascular system caused by maximum exercise training cannot be found.

[Myocardial infarction "with angiographically normal coronary arteries (author's transl)]. / Der "Herzinfarkt" mit angiographisch normalen Koronaraterien.

Within a cohort of 121 patients with clinical picture and electrocardiographic pattern of myocardial infarction four cases (3%) had normal coronary arteried demonstrated by selective coronary angiography. Two patients revealed no risk factors, two patients were heavy cigarette smokers. Mean age of patients was 34 years. Exact analysis of clinical, hemodynamic and angiographis data confirmed assumption of regional myoaggressive myocarditis as the underlying disease in one patient and suggested regional myocarditis with high probability in another case. The two other patients however could not be classified as having coronary or primary myocardial disease. The investigation suggests that some cases with the clinical and electrocardiographic pattern of "myocardial infarction" with normal coronary arteries may be due to regional myoagressive myocarditis.

[Heart size and left ventricular function in coronary artery disease: I. Heart size, exercise tolerance, cardiac output and filling pressures (author's transl)]. / Herzgrösse und linksventrikuläre Funktion bei der koronaren Herzerkrankung. I. Herzgrösse, Arbeitstroleranz, Förderleistung und Füllungsdrücke.

The possible relationship between the cardiac volume, as determined radiologically in the supine position in 119 patients with angiographically proven coronary artery disease, and the results of ergometry and balloon catheterization was investigated. There was no relationship between the heart size on the one side and the maximum exercise tolerance and the maximum cardiac output on the other, except for the fact, that these parameters tended to decrease with increasing heart size. This was especially true in patients with angina. The maximum cardiac output of patients with angina was always below the value of patients without angina but comparable heart size. Reduced cardiac output under exercise (exertional cardiac insufficiency) was present in 50% of patients with enlarged hearts but already in 22% of patients with heart volumes in the lower range of normal. The diastolic pulmonary artery pressure, determined under exercise, was the only parameter with a significant relationship to the heart size: The larger the heart size, the higher the diastolic pulmonary artery pressure. On the other hand: the diastolic pulmonary artery pressure at rest was abnormal with significant frequency only, when the heart was enlarged. Our data suggest, that the hemodynamics are determined by 2 factors: Myocardial scarring secondary to infarction and coronary insufficiency (ischemia). Of these two factors only the former influences cardiac size. Therefore, determination of the heart volume helps evaluating the respective role of these two factors in individual cases.

[Heart size and left ventricular function in coronary artery disease. II. Heart volume, coronary morphology and laevocardiogram (author's transl)]. / Herzgrösse und linksventrikuläre Funktion bei der koronaren Herzerkrankung. II. Herzgrösse, Koronarmorphologie und Lävokardiogramm.

We have investigated the possible relationship between the radiogically determined cardiac volume and the coronary angiogram and laevocardiogram. There was no relationship between cardiac size and coronary angiogram. Independently from the number of coronary vessels involved, we found normal sized hearts in patients without ECG-evidence of myocardial infarction, and enlarged hearts in patients with ECG-evidence of myocardial infarction. There was a significant, though loose relationship between the cardiac volume and the endsystolic and enddiastolic volumes (r=0.73 and 0.55 respectively) and the ejection fraction (r=0.69) as determined by laevocardiography. The critical value of the cardiac size, about which one encounters an increased number of abnormal volume parameters, was the upper boundary of 1-SD. Using this value we found a specifity of 81% and a sensitivity of 74% for the heart volume as a predictor of a pathological ejection fraction. On the other hand, using the upper boundary of 2-SD as a critical value, there was a sensitivity of only 58%, but a specificity of 92%. Only 11% of the patients with a cardiac size in the lower range of normal or below had an ejection fraction below 50%. Therefore the radiologically determined heart size is a simple, in daily practive acceptable method to assess and follow up left ventricular function in coronary patients.

Myocardial oxygen consumption and substrate uptake in man during physiological and pathological volume load.

It is shown in trained and untrained healthy individuals that the energy requirement of the physiologically hypertrophied heart is lower at rest and even more pronounced during submaximal heavy exercise compared to the non-hypertrophied state. This difference exceeds the changes which could have been anticipated by deviations in hemodynamics and total heart weight. In patients with mild or moderate aortic insufficiency the energy expenditure of the pathologically hypertrophied heart per unit tissue mass is comparable to the non-hypertrophied state at rest or during exercise. It is increased in severe aortic regurgitation or additional myocarditis. The transition from compensation to failure may be associated with a steep decreased of the metabolic and flow reserve of the whole heart.

Studies on the regulation of myocardial blood flow in man. I.: Training effects on blood flow and metabolism of the healthy heart at rest and during standardized heavy exercise.

In a comparative study 11 athletes and 11 untrained students were investigated at rest, of these 6 trained and 5 untrained individuals during exercise as well. Myocardial blood flow was measured by the argon method. Myocardial oxygen consumption, myocardial substrate uptake of glucose, lactate, and free fatty acids and cardiac output were determined by the direct Fick principle. Exercise was standardized according to 65% of an individual's maximal oxygen uptake (delta VO2 max). Coronary flow reserve was determined by dipyridamole injections. All measurements were made during hemodynamic and respiratory steady-state conditions with the subject in a supine position. At rest, myocardial blood flow and myocardial oxygen consumption were significantly lower in trained subjects compared to the untrained ones. These differences were more pronounced during heavy exercise. They cannot be explained completely by hemodynamic parameters. - During exercise, myocardial substrate uptake shifted to a predominant lactate uptake of almost 90% of total substrate uptake. Total substrate uptake as well as lactate uptake correlated significantly with myocardial oxygen. - Coronary flow reserve was lower in the trained group. It is concluded that the heart muscle of a trained individual requires less energy at a given work load than in the untrained state.

[A variant analysis of static body mass, height, surface area, radiological heart volume and aerobic capacity. Comparison findings between 200 high performance athletes with 80 untrained persons (author's transl)]. / Varianzanalyse der statischen Körpermasse Gewicht, Grösse und Oberfläche, des röntgenologischen Herzvolumens und der aeroben Kapazität -- ein Vergleich zwischen 200 Hochleistungs - sportlern und 80 Normalpersonen

Static body mass and parameters of aerobic capacities were investigated in 200 high performance athletes and 80 untrained persons. The results were subjected to a variant analysis. A subdivision of the athletes into strength and endurance sports has been shown to be of value. The mean range in untrained persons, strength athletes, endurance sports athletes and other athletes is presented. Significant variations were observed. Body mass, height and surface area was measured and the findings in athletes and untrained persons were compared. From the variant analysis of absolute and relative heart volume, the statement can be made, that athletes have larger hearts and that differences between sports exist. On the average the maximal O2-Puls and maximal Wattpuls as a measure of the aerobic capacity are greater in trained than in untrained persons. A close correlation between maximal O2-Puls and Wattpuls was demonstrated. Between strength and endurance athletes significant differences in both parameters are observed. A comparison of several statistics from the West German sport medicine literature of recent decades has shown, that in spite of changes in training quality and quantity in high performances athletes no evidence could be found for an increase in the performance parameters of the aerobic capacity.

[Clinical and hemodynamic aspects of myocardial diseases (author's transl)]. / Klinische und hämodynamische Aspekte der Herzmuskel-erkranhungen

Definition, arrangement into primary and secondary forms and classification of myocardial diseases are used irregularly in the literature. The great variety of clinical and hemodynamic parameters are shown with reference to our own patients and an attempt is made to arrange them in individual types. Followup examinations show that signs of congestive failure, heart size and other clinical and hemodynamic parameters may be considerably altered. For this reason it is proposed to describe myocardial diseases accoridng to clinical and hemodynamic parameters in order to obtain a closer insight into the pathomechanism of these diseases.

[Function improvement in levography following aortocoronary bypass]. / Funktionsverbesserung im Lävogramm nach aorto-koronarer Bypass-Operation

Actively contracting segments, preoperatively akinetic, were found in 8 of 63 patients, evaluated 6-12 months after aortocoronary surgery by coronary angiography. Ejection fraction was increased from 48.1% (S.D. 15.7) to 68.3% (S.D. 11.4). These patients are characterized by two simple clinical parameters: 1. All patients had angina pectoris at rest or at minimum exercise except for one; 2. preoperatively, there was a discrepancy between severe ventriculographic and discreet Ecg findings. These findings prove that myocardial function in coronary artery disease can be impaired at rest by ischemia, without clinical signs of coronary insufficiency, such as angina pectoris. Even severe impairment of left ventricular function is no contraindication for coronary artery surgery, if caused by reversible myocardial ischemia.

[Clinical course of arteriosclerosis of coronary and lower limb arteries (author's transl)]. / Der Verlauf der Arteriosklerose an den Koronar- und Beinarterien. Eine Untersuchung an 34 nachangiographierten Patienten

The clinical course of arteriosclerosis was evaluated in 9 patients with coronary sclerosis and in 25 with peripheral arterial occlusive disease by means of repeat angiographies following primary angiography after 22.5 and 36.6 months, respectively. During the period of observation arteriosclerosis had progressed in all cases except in two patients with peripheral arterial occlusive disease. Despite intensive therapeutic efforts including control of risk factors, dietary care, guided or unguided exercise and the attempt to change unsatisfactory living conditions, progression of arteriosclerosis could not be interrupted. If treatment delayed progression of arteriosclerosis cannot be decided. All vascular areas were affected indiscriminately by progression and no particular localisation was preferred. Intensive exercise does not seem to delay progression of arteriosclerosis.